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Azathioprine Safe Pregnancy AAV Maintenance — ESENeph MCQ

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ModeratePregnancy & RenalAzathioprine Safe Pregnancy AAV MaintenanceESENeph

A 29-year-old woman at 8 weeks' gestation has known ANCA-positive granulomatosis with polyangiitis in stable remission on azathioprine 150 mg daily and prednisolone 5 mg daily. She stopped rituximab 8 months ago. Her ANCA is negative and eGFR is 72 mL/min/1.73m2. What is the MOST appropriate immunosuppression strategy during pregnancy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Continue azathioprine and prednisolone

Azathioprine is considered safe in pregnancy (BNF, BSR, EULAR guidance) and should be continued to prevent vasculitis relapse, which would be far more dangerous for mother and fetus than the medication. The metabolite 6-TGN does not cross the placenta efficiently because the fetal liver lacks inosinate pyrophosphorylase. Low-dose prednisolone (≤10 mg) is also safe. Mycophenolate and methotrexate are both teratogenic and absolutely contraindicated. Stopping all immunosuppression risks severe vasculitis relapse. Close monitoring of eGFR, proteinuria, and ANCA throughout pregnancy is essential. Plan delivery in a centre with renal/rheumatology input.

Reference: BSR 2017 – Prescribing in Pregnancy; KDIGO 2024 – AAV Guideline; BNF 2024 – Azathioprine in Pregnancy: https://ukkidney.org/health-professionals/guidelines/clinical-practice-guideline-pregnancy-and-renal-disease